Approach Considerations

The goal of treatment is to reduce pain and to return to activity. Nonpharmacologic treatments of tendinopathy are as follows:

Rest or decrease activity level. No clear recommendations are available for the duration of rest; however, patients should restrict activities that cause pain.

Ice is recommended for the first 24-48 hours.

Splinting and/or immobilization; sling for rotator cuff tendonitis

Strengthening and stretching exercises can be performed once the pain has subsided. Eccentric strength training can be effective in treating tendinopathies.

Low-intensity pulsed ultrasound was shown to be no more effective than placebo in the treatment of patellar tendinopathy.
[5] Transcutaneous electrical nerve stimulation (TENS) provided no benefit over primary care management in a randomized trial in 241 adults with tennis elbow.
[6]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving tendinopathy pain, and may be administered topically or orally. However, because the vast majority of tendinopathies are not inflammatory, whether NSAIDs are more effective than other analgesics is unclear.

Corticosteroid injection may be considered for patients with tendonitis in whom conservative therapy with rest, immobilization, and anti-inflammatory agents has failed.The corticosteroid (eg, triamcinolone) is typically combined with a local anesthetic (eg, lidocaine) to provide prompt analgesia; in addition, pain relief confirms the diagnosis and accurate placement of the corticosteroid.

The efficacy of locally injected steroids is debated. A systematic review concluded that steroid injections provide short-term pain relief but may not have long-term efficacy.
[7] Response to injection therapy may vary with the anatomic site of tendinopathy.

Never use injections for Achilles tendonitis, because cases of Achilles tendon rupture have been reported following a single injection of corticosteroid. Avoid repetitive corticosteroid injections in any site, as well as injection directly into a tendon, because of the risk of tendon rupture.

In patients with calcific tendonitis of the shoulder, a systematic review concluded that ultrasound (US)-guided needling and lavage has a high success rate and low complication rate.
[9] In a randomized controlled study in 48 patients with calcific tendonitis of the rotator cuff that compared the combination of barbotage and US-guided corticosteroid injection in the subacromial bursa with subacromial bursa injection alone, both treatment groups demonstrated improvement at 1-year follow-up, but clinical and radiographic results were significantly better in the barbotage group.
[10] After US-guided treatment, recovery may be enhanced by use of a rehabilitation protocol that focuses on mobility, strength, and function.
[11]

A retrospective evaluation of double-needle US-guided percutaneous fragmentation and lavage (DNL) in 147 patients with rotator cuff calcific tendinitis found DNL to be safe and effective, with prompt relief of pain and function restoration.
[12] However, a systematic review of the efficacy of US-guided needle lavage in treating calcific tendinitis found a lack of high-quality evidence to determine the relative efficacy.
[13]

Surgical therapy

Patients with symptoms resistant to conservative therapy may benefit from arthroscopic or open surgical treatment for tendon decompression and tenodesis. A Japanese study in 23 patients with chronic lateral epicondylitis who underwent arthroscopic surgery found that the procedure provided significant improvement in pain and functional recovery up to 3 months after surgery. However, the visual analog scale (VAS) for pain and satisfaction criteria during activity did not fall below 10 points until 6 months postoperatively.
[14]

Isolated gastrocnemius recession has been shown to provide significant and sustained pain relief for chronic Achilles tendinopathy. Good function can be expected for activities of daily living, however ankle plantarflexion power and endurance deficits were noted.
[15, 16]

Platelet-rich therapies

Platelet-rich therapies represent an experimental approach to treatment of tendinopathies and other musculoskeletal soft tissue injuries. In this technique, a quantity of the patient's blood is centrifuged and the active, platelet-rich fraction is extracted and applied to the injured tissue (eg, by injection). In theory, the growth factors produced by platelets should enhance tissue healing. Although platelet-rich therapies are gaining wider use, a Cochrane review concluded that at present there is insufficient evidence to support the clinical use of platelet-rich therapies.
[17]

Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.

Speed test.

Yergason test.

The proximal patellar tendon is most commonly affected in jumper's knee.

Iliotibial band at the lateral femoral condyle, with the posterior fibers denoted.

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences